Military Mental Health — A Contradiction?

I was commissioned a captain in the United States Army in a northern Midwest city.  The physician who examined me before I took the oath was senior and experienced and as avuncular as they come.

He said the most interesting people (and far and away the smartest) he got to meet in his life were commissioned women.  The one he had seen before me was a woman who had been a professional musician, a clarinetist I think, and was going straight to Wahington, D.C. to play in a dance band at the White House.  He told me about women rocket scientists and others. Me, I figured I was only a doctor, a half-trained neurosurgeon.  As a generalist he felt somehow he needed to show me enough respect. He really didn’t want to do a physical, so he did a cursory and discrete one, and I asked him about being a civilian physician attached to the military.  In particular, I asked him about neurological and psychiatric screening. Although he told me he knew how to do a pretty detailed neurological examination, he said he never had to do one.  Anyone with that kind of illness would, he thought, be likely to be screened out long before. After all, these were generally healthy young men.  Basically, the most important part of the examination was checking them for hernias.

Mental health screening?  He shrugged.  He said he asked everyone if they heard voices or had any experiences other people didn’t have.  (I had plenty of experiences that other people did not have, what with this “little girl genius” thing.  Good thing I didn’t tell him.)  And he did ask them if they wanted to kill themselves, or anyone else who was not the enemy. I remember vividly that he lost eye contact with me at that point, and I wondered if he even asked those questions. I remember learning that “shell shock” — some kind of Post Traumatic Stress Disorder variant — was first described during the Civil War.  I do not know if the story I heard when I hung out a bit at the Menninger Institute was true or not, but I heard from some different folks that the “great old man” — the founding Dr. Karl Menninger — had been asked by the military, the Army in particular, if he could help them screen out the soldiers who would later have trouble in combat. He said he would only do it if given the rank of general, which does not exactly get handed out, so that never happened. During most of my training, anywhere and everywhere, I was told that the weakest thing any psychiatrist could be asked to do was to predict any kind of human behavior — the best bet being that if someone had done something before, they were extremely likely to do it again, even if they did not think they would. Now, I doubt I would trust the Army to investigate itself, but they give us more hints on something they consider an internal publication. Less suicides in combat, maybe.  More among reservists, maybe.  The person interviewed here has the gallantry to admit he does not know what the hell is going on.

Here is the Army internal reporting of the current study .

If you don’t mind a PDF article popping open on your screen, here is the abstract from the original American Journal of Psychiatry article, with a link to the entire PDF file if anyone is so inclined. The study is well constructed with decent statistics, which is exactly what we expect from folks getting published at this level. The question is simply what the study shows. It shows that having in place a psychiatric screening may predict serious stuff like suicidal ideation or major mental illness requiring treatment while people are actually fighting. Initial screenings are done by primary care physicians.  Not bad. Later follow up assessment by psychiatrists.  Not bad.  We are comparing a group of three units who got this with three units who did not.  Is anybody surprised there is a difference?

Whatever.  Maybe somebody had to do this to prove something.  Maybe somebody needed publications to get rank.  

Screening in more detail to get more detailed psychopathology is not really predicting human behavior, which I still do not think anyone can do terribly well.  It is seeing if someone already has psychopathology which is likely to repeat itself, which is a good thing certainly.  

Psychotics tend to have more than one break.  Bipolars tend to cycle repeatedly. Suicidal ideation, once experienced, can and does often return.  The sun manages to rise every morning. It is only a first step, festooned with wild optimism in the internal Army reporting. The internal Army reporting tells about sending some doctors into the theater of operations, following and treating people just as it would have been done at home.  Nice.  In this day and age, perhaps a bit more than “chicken soup.”  I think. I was told for the “chicken soup” nurturing I would be stationed 6 to 8 miles behind the front lines, so I probably would not get shot, and could show people my card that said in something like 12 languages “don’t shoot me, I’m a doctor.” Me, I was in a peacetime army where I spent a lot of my time getting people out on a psych discharge —  Eighteen year olds crying for their mothers. Criminal types whose commanding officers told me were “disordered in the personality” and every single time they were, for I had told them to their amazement I was not going to lie, and I did not have to. Some people should not be in the military because having them in the military is good neither for them nor for the military nor for the U.S. of A.  We are talking pre-recruitment not pre-deployment.  I have never heard of anyone attempting to screen these folks.  With war going on, there is a major problem with getting enough soldier bodies. Most of the reporting about how military recruiters are doing with their quotas seems mysteriously to have disappeared in the last few years, but I doubt this problem has.  Lowering standards to increase numbers.

This is one of the more powerful of the many concerning reports of people trying to start military recruitment…in middle school. So it is difficult to tell what if any of these fine measures, described in this fine if fairly obviously inferential piece of clinical research we started out to report will see their way into happening.  Assuming the cost in physicians’ salaries is not too horrific, it can be compared to the cost of medically evacuating those who become grossly psychotic on the front lines.  I suppose some form of this screening, although perhaps stripped down because of budget problems, could happen. It is the tip of an iceberg. I firmly believe that combat is one of the highest stress situations that anyone can imagine. There have got to be people who have psychiatric troubles who have never had them before. Two particular areas of psychiatry have already been isolated that the military may have trouble identifying, let alone treating: Post Traumatic Stress Disorder and (admittedly, some do not consider this psychiatry but I do)and allegedly “mild”  traumatic brain injury.There is now no screening and little effective treatment.  Maybe it is possible to cut down a little on the Post Traumatic Stress Disorder if you can weed out someone who has the symptoms from, for example, having been beat up by his stepfather.  He (or she) might be more likely to generate symptoms when beat up by the enemy. Traumatic Brain Injury is obviously unpredictable. What these two conditions have in common is that throwing pills at them is never enough.  And to my knowledge, the most effective treatments (Emotional Freedom Technique and the like) are not even used or endorsed by the military and feds. The leftover problem that seems to be continuing to increase is the suicide among reservists. There is one hint back in that article about what may be going on.  Assuming for the moment that suicide prevention might help, there is little relevant communication to soldiers on active duty and doubtless little if any to reservists. The “need to know” mentality of the Army is a historic value. Electronic  communication might be an answer here, but somebody has to actually do it.  Not as a research study but as a reality.  That takes human power. The wars waged by this country seem to continue on the same principles which make no sense except economic — increasing warfare to permit a deceleration later. The notions of human capital being lost, parents crying over the death of active duty military which seem to be consistently sacrificed for purposes that are “political” — meaning economic. I was being interviewed for a high level military position which I did not get.  I had been invited to a place called the “Eagle’s Nest” because almost everyone there had an eagle for their status of Colonel on their uniform.  At that time they were all male.

One of them asked me about the eagle I wore around my neck, a gift from my parents who wanted me to remember Isaiah 40:31—

“But they that wait upon the Lord shall renew their strength; they shall mount up with wings as eagles; they shall run, and not be weary; and they shall walk, and not faint.”

It was not, as they thought, my desire to be a colonel. They joked.  They could not drink there, so planned to meet off-base afterward. They thought that the ideal soldier for the front line would be a grossly psychotic, with a kamikaze mentality, who would kill everything in his path. I managed to avoid vomiting, and certainly could not laugh, because deep down I knew, they were probably right.

I don’t think these colonels would want such psychos screened out.

Many times I’ve heard that old joke that “Military Intelligence” is an oxymoron – a contradiction of terms.

Both then and now I wonder if Military Mental Health might also be an oxymoron. At any rate — I am happy I did not get that job.